The Impact of Closed ICUs on Neurosurgical Practice
Based upon reported concerns over the impact of closed intensive care units (ICUs) on training programs, as well as on community neurosurgeons and their ability to maintain critical care management skills, a survey was created by the Council of State Neurosurgical Societies (CSNS) and distributed to a standard list-serve of the American Association of Neurological Surgeons (AANS). Five hundred and ninety-eight responses were obtained. Twelve percent of program directors responding reported that their patients were cared for in ICUs closed to their residents and one-third (31%) felt that closed units negatively impacted their trainees. In the community, nearly half (46%) of the neurosurgeons responding reported ICUs closed to them in their primary hospital, and over half (51%) felt negatively impacted by closed units. Concerns included degradation of critical care skills, lack of improved outcomes, overall quality and cost in closed ICUs. These access issues will require ongoing surveillance by neurosurgical leaders in the coming years.
Traditionally, most neurosurgical ICU patients, including post-operative and nonsurgical patients, were primarily cared for by neurosurgeons with medical and critical care consultation secondarily.
Consequently, all neurosurgeons, both in and after training, received extensive exposure to these patients and education regarding this highly specialized care. In the last several years, however, the care of these same patients has changed in a variety of ways. Standardization of protocols for control of elevated intracranial pressure, ventilator management and sepsis are just a few examples of advances in care.
In an effort to further improve critical care outcomes, many hospitals have employed closed model systems for their ICU in which only the critical care medicine staff may admit and manage patients. In these systems, this staff is obligated to provide 24-hour coverage (1,2). Hybrid models also exist where certain other specialties may admit and manage patients, but these privileges are not necessarily extended to all physicians on the medical staff. Within many of these models, writing orders may be allowed only by critical care specialists. While the creation of closed ICUs has been predicated on the notion that they may result in reduced mortality and shorter ICU length of stay, this idea is not universally supported by the literature (3,4). In addition, concerns have been voiced that reduction in exposure to the most critically ill patients, both in training and practice may impact the ability of neurosurgeons to learn and maintain critical care skills.
Therefore, the goal of this study was to understand the impact of closed ICUs on neurosurgical practice, including the assessment of variability in management practices by neurosurgeons in the ICU, the potential impact on neurosurgical resident training as well as on community neurosurgeons maintaining their skill sets in neurocritical care.
In response to Resolution X – 2012S, passed by the plenary of the CSNS in spring 2012, an online survey was created by the CSNS Neurotrauma and Emergency Neurosurgery Committees in accordance with standard survey guidelines. Members of the CSNS Executive Committee further vetted the survey through several iterations. The e-survey was designed to assess the impact of closed ICUs on neurosurgical resident training and practice. The survey was created in Survey Monkey (Palo Alto, Calif.), and was first distributed in November 2012 with responses collected through April 2013. Several interim notifications were sent to stimulate responses and separate notifications were sent specifically to residency program directors in Accreditation Council on Graduate Medical Education (ACGME)-approved training programs.
The audience for the survey was neurosurgeons in the United States and was distributed to all members of the AANS, including fellows (full active membership), lifetime, provisional and candidate members. For the purposes of this survey, only North American neurosurgeons in training, in active practice, or retired from active practice were surveyed. Fellows of the AANS defined as neurosurgeons who are certified by the American Board of Neurological Surgeons, the Royal College of Surgeons of Canada, or Mexican Council of Neurological Surgeons and residing in the United States, Canada or the Republic of Mexico. Provisional members are those members who have completed residency training approved by the ACGME, the Royal College of Surgeons of Canada or the Mexican Council of Neurological Surgery within the past five years, but who are not yet eligible for full fellowship pending board certification. Candidate members are those members who are currently participating in a residency or fellowship training program approved by these same accreditation bodies.
Survey Response and Demographics
A total of 1,200 surveys were emailed with responses from 564 (47%). Of these, only 507 (90% of respondents) completed sufficient answers to be included in the final data analysis. There were 51 respondents who self-identified as residency program directors (49% of 105 ACGME-accredited neurosurgical training programs) based on the 2012 RRC directory of U.S. residency programs) and of these, reliable responses about resident education impact were available for 24 (47%) respondents.
Of the survey respondents, 551 answered questions about their AANS membership. Some 410/551 (74%) were fellows of the AANS, 40/551 (7%) were lifetime fellows, 46/551 (8%) were provisional members, and 55/551 (10%) were candidate members. Five hundred and eight respondents answered regarding concurrent membership in the Congress of Neurological Surgeons (CNS).
The different types of medical practices among 558 respondents can be found in Table 1. Approximately 87 percent (483/558) of respondents were attending physicians with full admitting privileges for neurosurgical patients at their primary hospital and 11 percent (64/558) were residents/fellows with full privileges for neurosurgical patients. Others reported limited privileges for neurosurgical patients, privileges in another specialty, or no active staff privileges (but were members of a group practice at their hospital). Closed ICUs were reported by 16/51 (31%) program directors at a primary or secondary hospital utilized to train their residents.
Global ICU Access
Of the respondents reporting full neurosurgical privileges (n = 542), 485/542 (89%) reported full access to their primary ICU. The remaining 11 percent (57/542) reported either restricted access (48/542; 9%) or no access at all (9/542; 2%). Half of all respondents (278/545) reported more than 50 ICU admissions over the last 12 months, with an additional 25 percent (140/545) having 21-50 ICU admissions over the same period. The remaining respondents had 11-20 ICU admissions (74/545; 13%), 1-10 admissions (44/545; 8%) or no admissions (9/545; 2%) over the last year. Closed ICUs present in at least one hospital were reported by 25 percent (134/537), and an additional 18 percent (95/537) stated that while there wasn’t a closed ICU, their hospital had considered it. Subsequent responses about closed ICUs were obtained from all respondents that indicated the presence of at least one closed ICU at the main hospital at which they are on staff.
Neurosurgical ICUs within Residency Training Programs
Program directors reported completely closed ICUs at their institution in one-third of cases (6/18). Half of these same respondents (8/16) stated that ICU beds were available to neurosurgery staff but not to staff from other disciplines. In cases where some, but not all ICU beds were closed, roughly half indicated that greater than 60 percent of beds were closed. Among program directors with closed ICU beds at their institution, 70 percent stated that this situation has arisen within the last five years. These same respondents indicated that the subspecialists retaining privileges in ICUs closed to neurosurgical staff were intensivists (90%) and anesthesiologists (55%) (more than one response was allowed).
Overall, in 92 percent (11/12) of programs, residents were involved to some degree in treatment and decision-making in the ICU closed to neurosurgery staff. However, significant concerns still exist because 31 percent (4/13) of program directors with closed ICUs felt it was having a negative impact on resident education (Table 2). Similarly, the constraints set forth by a closed ICU were judged to have affected residents’ abilities to meet the objectives set forth by the Society of Neurological Surgeons (SNS) Committee on Resident Education (CoRE) curriculum in 23 percent (3/13), (38% [5/13] indicating “no,” and 38 percent [5/13] indicating “not sure”).
Nearly a third (3/10, 30%) indicated that the Leapfrog ICU Physician Staffing Standard (The Leapfrog Group) was either the sole reason, or one of several reasons, that closed ICUs were implemented at their hospital.
Over half (8/14) of responding program directors indicated there was a neurosurgeon as director or co-director of the ICU at their residency institution. Of these, 22 percent (2/9) completed a fellowship in neurocritical care that was separate from neurosurgery residency and one third (3/9) completed residency training after the year 2000.
Neurosurgical ICUs in Non-teaching Hospitals
Outside of teaching institutions, in the community at large, nearly half (53/114, 46%) of respondents reported their patients being cared for in closed ICUs. Another 33 percent (38/114) reported ICUs that were open to neurosurgery staff admissions but not to staff of other disciplines.
These closed ICUs are a primarily recent phenomenon, with 60 percent (45/75) having been closed for less than five years. In these closed ICUs, control of patient care is by intensivists (74/81, 90%), general surgeons (32/81, 40%) and anesthesiologists (25/81, 31%) [Multiple responses were allowed]. While 77 percent (68/88) of respondents stated they were involved in the treatment decisions and orders for their own patients admitted to ICUs closed to neurosurgery staff, 23 percent (20/88) indicated that they were not involved.
The impact of closed ICUs on various aspects of practice is detailed in Table 3. Almost 50 percent (42/85) of respondents stated that the decreased access to the ICU has jeopardized their ability to maintain critical care skills (Table 4). Assessments of outcome quality included 68 percent (56/82) perceiving no benefit in improved quality of care, reduced mortality, reduced cost of care or other benefits for their patients admitted to the closed ICU. Thirty-four percent (31/92) of respondents stated that their hospital has not yet even attempted an analysis of the data on the impact of their ICU policy on quality, mortality, and/or cost of patient care.
When asked if the decision to have a closed ICU was in response to the Leapfrog ICU Physician Staffing Standard, 62 percent (52/84) didn’t know, or were unaware of the standard, while 21 percent (19/84) indicated that it was the sole, primary or one of several reasons for policy adoption.
Seventy-eight percent (80/103) of respondents stated that their hospital does not have a neurosurgeon as director or co-director of their ICU. Of neurosurgeon directors, 78 percent (18/23) did not complete a separate fellowship in neurocritical care. Respondents indicated that this neurosurgeon completed his/her residency prior to 1990 (17%, 4/23), in the 1990s (44%, 10/23) or after 2000 (39%, 9/23).
Formal assessments concerning the value of closed ICUs for the general patient population began to appear in the literature 20 years ago. One study from 1996, suggested that closed ICUs were associated with lower observed (versus predicted) mortality, lower resource utilization for the sickest patients and increased nursing confidence in the physicians directing medical care (5). Six years later, a systematic review of critical care staffing found that ICUs with dedicated intensivists managing patients were associated with lower mortality and shorter hospital and ICU length of stays (4). Similar results were confirmed by others (6-9). Similar observations have been made when assessing 24-hour dedicated intensivist staffing versus traditional resident night coverage in ICUs (8). Transitions to closed ICUs have also been associated with increased surgical resident job satisfaction (10). However, more recent studies have disputed that the improved outcomes are a result of 24-hour intensivist staffing and closed ICU status (3).
Restricting admission access to practicing neurosurgeons caring for patients in the ICU is a relatively new phenomenon observed in the last several years. This has sprung from the idea that dedicated intensive- care specialists care most effectively for the overall ICU patient population. Intuitively, this would appear to be a valid extrapolation given prior literature regarding critical care in other disciplines. However, while there is data supporting the notion of closed ICUs for medical and general surgery patients, the body of literature surrounding the care of critically ill patients with neurologic illnesses is currently evolving.
Significantly, there remains the central question of what type and duration of training qualifies a practitioner to care for patients with neurologic illness in the ICU. In many areas of North America, ICUs have become closed to neurosurgeons who have not passed recently created certification exams, without acknowledgement of their long and robust training in ACGME-accredited programs. Indeed, neurosurgery led the development of critical care for neurosurgical patients. In recent years, organized neurosurgery has developed even more precisely defined goals and milestones for this portion of resident education (the SNS Matrix curriculum) in order to consistently provide the knowledge base, skills and experience necessary to manage neurosurgical ICU patients competently. This dedication to overall patient care has ensured that board-eligible and board-certified neurosurgeons have the competency to care for their own patients in the ICU, with results that are comparable to or exceed those of cases where care is transferred to a practitioner in another discipline without involvement of the primary neurosurgeon.
ICU physician staffing practices have been the focus of increasing attention by various regulatory and advisory bodies, including the Leapfrog Group for Patient Safety (11). This group is a consulting body to a consortium of large corporations whose aim is to define mechanisms of improving patient outcome and reducing the cost of health care amongst their employees/beneficiaries. Since its inception, many U.S. hospitals have adopted the Leapfrog principles for ICU staffing. One result of this has been limitation of admission privileges to ICUs to only those with specific critical-care training beyond residency, or with critical care certification. One such certification adopted by the Leapfrog Group as sufficient for provision of neurointensive care was that provided by the United Council for Neurologic Subspecialties (UNCS). Published criteria from the Leapfrog Group for neurointensivists are as follows:
“Neurointensivists are an approved alternative to intensivists in providing care in neuro ICUs. Neurointensivists are classified as neurologists and neurosurgeons who are board- certified in their primary specialty and who have completed an United Council for Neurologic Subspecialties (UCNS) certified fellowship training program in neurocritical care, or a physician who is board certified in neurocritical care. Existing physicians must obtain certification using the grandfathering process established by UNCS to be considered a neurointensivist.”
The UCNS was formulated in 2003 as a mechanism for accrediting the smaller subspecialties within the field of Neurology, as approved by the five “parent” neurology associations: the American Academy of Neurology, the American Neurological Association, the Association of University Professors of Neurology, Child Neurology Society, and Professors of Child Neurology. It is a “nonprofit organization that accredits training programs (fellowships) in neurologic subspecialties and awards certification to physicians who demonstrate their competence in these subspecialties” (12). It has developed a curriculum for fellowship and certification for neurocritical care in conjunction with the Neurocritical Care Society, which also began in 2003 as a multidisciplinary society with several neurosurgeons as charter members.
Neurosurgeons participate actively within the organization to the present time. The UCNS neurocritical care fellowship has been open to practitioners of various specialties, including neurosurgeons, and a grandfathering process for those who have been in the active practice of neurocritical care was adopted (but it required passage of a written examination provided by the UCNS). However, the UCNS fellowship and certification pathway is not yet certified by the American Board of Medical Specialties (ABMS).
The American Board of Neurological Surgeons (ABNS), in contrast, has been an ABMS-recognized board since 1940, and includes, as part of the initial and maintenance of certification processes for neurosurgeons, assessment of the ability of neurosurgeons to provide aspects of critical care to their patients. Specifically, the ABNS defines neurosurgical practice as that which “encompasses both non-operative management (e.g. prevention, diagnosis — including image interpretation — and treatments such as, but not limited to neurocritical intensive care and rehabilitation) and operative management with its associated image use and interpretation (e.g. endovascular surgery, functional and restorative surgery, stereotactic radiosurgery and spinal fusion – including its instrumentation.” Written and oral examinations include extensive critical care content.
The ACGME and the Neurological Surgery Residency Review Committee (RRC) also require comprehensive education and training in neurocritical care during residency. The Milestones project of the ACGME has been implemented in U.S. neurosurgical training programs as of 2013, with a module dedicated to neurocritical care milestones.
Finally, the SNS, which is the American society of leaders in neurosurgical residency education, has set forth specific criteria for the instruction of neurocritical care for neurosurgical residents, having developed the Neurocritical Care Core Curriculum for training programs recognized by the RRC. Neurocritical care fellowship training curricula have also been developed by the Committee on Advanced Subspecialty Training (CAST) as a further mechanism to provide neurocritical care education either during an enfolded fellowship, during residency or during a post-residency fellowship training period.
Certification processes have been developed with a grandfathering process provided for those neurosurgeons who have been providing neurocritical care as a major portion of their practice prior to the development of fellowship training, and who have had Neurosurgical ICU director experience. While the practice of neurosurgeons caring for their own patients in an ICU setting does not require such additional training or certification, going forward it is recognized that the direction of Neurosurgical ICUs and hands-on neurointensivist staffing of neuro-ICUs may require additional subspecialty training. This certification is also open to specialists from other training backgrounds besides neurosurgery.
At no point has it been the stated intent of the UCNS to prohibit other specialties from providing their own certification or training requirements in neurocritical care, nor to specifically identify the UCNS as the sole purveyor of said certification. Indeed, collaborative efforts are underway between the SNS and the UCNS with respect to potential for shared neurocritical care training program resources.
In response to the Leapfrog Group’s historically narrow definition of neurocritical care, as including only physicians who are certified by the UCNS, leaders within organized neurosurgery led a communications effort with the leadership of the Leapfrog Group, culminating in an in-person meeting in early 2014. Several communications delineating the principles of neurocritical care education required of all ACGME-accredited neurosurgical residency and fellowship training programs in the U.S. were provided in advance of the discussion. As a result of these efforts, the Leapfrog Group is considering amended language (with some preliminary approvals having been gained) to include neurosurgical training and certification, the final approval of which is pending at the time of this writing.
The results of the survey described in this publication clearly reflect several concerns within the neurosurgical community. Closed ICUs are present within a number of training programs, and a third of academic respondents felt that this had a negative impact on their trainees’ experience, with another third not yet being sure of the effect. As the impact of closed neuro-ICUs becomes better delineated in the future, we must continually assess our ability to train residents; if access to neurosurgical education in the ICU is limited, future neurosurgeons may find themselves less well equipped to care for their own surgical patients, and as a result, patient outcomes may become jeopardized. It is imperative that these trends be followed closely by neurosurgical program directors to fully appreciate the educational impact of any emerging trends in changes to patient access in the ICU.
Among practicing neurosurgeons, the problem seems to be even more significant. Overall, almost half of respondents reported closed ICUs in their primary institution (46%), and a quarter (23%) did not participate in management or decision-making at all. As would be expected, over half (51%) felt negative impacts from their restricted ICU access in terms of maintaining critical care skills. The majority (64%) also felt that the restriction in access has not improved care, reduced mortality, or reduced cost to their patients. As there are many community neurosurgeons who incorporate critical care as a core component of their daily practice, there is an economic impact present as well, although this does not seem to be a primary concern for most.
In conclusion, neurosurgeons should not be restricted or prohibited from participating in the care of their own patients in the ICU. This care includes the formulation of differential diagnoses, development of treatment plans, initial stabilization of neurosurgical and neurologically critically ill patients, performance of neurosurgical procedures, and provision of subsequent critical care, post-operative care, and long-term follow-up care. The unique range and depth of neurosurgical skill is acquired throughout a lengthy training process which incorporates detailed instruction in neuroanatomy, neurophysiology, neuroradiology, neuropathology, and critical care. Neurosurgeons gain expansion of professional expertise over the course of a neurosurgical career and serve an integral function to the critical care of neurosurgical patients. Survey results indicate that some unintended consequences of restriction of admission privileges for neurosurgeons with patients in ICU settings may impact neurosurgical training and practice, with implications for patient outcomes. Further detailed information from future studies will be needed to assess the impact of this practice, especially in view of changing criteria utilized by hospitals for admission privileges and ICU staffing.
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